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Vermont Health Care Power of Attorney Form

The Vermont health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.

Vermont Health Care Power of Attorney Form
Durable Power of Attorney for Health Care Vermont
Standard Form
(Please print clearly, except where signature is required)
I, ………………………………………………………….. of ……………………………....……., hereby appoint
…………………………………………………… of ………………………………….., as my agent to make any
and all health care decisions for me, except to the extent I state otherwise in this document. This durable
power of attorney for health care shall take effect in the event I become unable to make my own health
care decisions. Should the person I have appointed be unable, unwilling or unavailable to act as my
health care agent, I hereby appoint
..................................................................................... of ……………………………………………. as my
alternate agent.
A. STATEMENT OF DESIRES, SPECIAL PROVISIONS AND LIMITATIONS REGARDING HEALTH
CARE DECISIONS. Here you may include any specific desires or limitations you feel are appropriate,
such as when or what life-sustaining measures should be started or withheld; directions whether or not to
use artificial nutrition and hydration; or instructions to refuse any specific types of treatment that are
inconsistent with your religious beliefs or unacceptable to you for any other reason. (If you want to include
instructions about life-sustaining treatment, read Part B before filling out this section.) (attach additional
worksheets or pages as necessary)
B. THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR IMPORTANCE. For
your convenience in dealing with this subject, some general statements concerning life-sustaining
treatment are set forth below. IF YOU AGREE WITH ONE OF THE STATEMENTS, YOU MAY COPY IT
IN THE SPACE PROVIDED ABOVE.
1. If I suffer a condition from which there is no reasonable prospect of regaining my ability to think
and act for myself, I want only care directed to my comfort and dignity, and authorize my agent to
decline all treatment (including artificial nutrition and hydration) the primary purpose of which is to
prolong life.
2. If I suffer a condition from which there is no reasonable prospect of regaining the ability to think
and act for myself, I want care directed to my comfort and dignity and also want artificial nutrition
and hydration, if needed, but authorize my agent to decline all other treatment the primary purpose
of which is to prolong my life.
3. I want my life sustained by any reasonable medical measures, regardless of my condition.
Vermont Health Care Power of Attorney Form
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